1
|
Chaaban H, Burge K, McElroy SJ. Evolutionary bridges: how factors present in amniotic fluid and human milk help mature the gut. J Perinatol 2024:10.1038/s41372-024-02026-x. [PMID: 38844520 DOI: 10.1038/s41372-024-02026-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 08/22/2024]
Abstract
Necrotizing enterocolitis (NEC) continues to be a leading cause of morbidity and mortality in preterm infants. As modern medicine significantly improves the survival of extremely premature infants, the persistence of NEC underscores our limited understanding of its pathogenesis. Due to early delivery, a preterm infant's exposure to amniotic fluid (AF) is abruptly truncated. Replete with bioactive molecules, AF plays an important role in fetal intestinal maturation and preparation for contact with the environment, thus its absence during development of the intestine may contribute to increased susceptibility to NEC. Human milk (HM), particularly during the initial phases of lactation, is a cornerstone of neonatal intestinal defense. The concentrations and activities of several bioactive factors in HM parallel those of AF, suggesting continuity of protection. In this review, we discuss the predominant overlapping bioactive components of HM and AF, with an emphasis on those associated with intestinal growth or reduction of NEC.
Collapse
Affiliation(s)
- Hala Chaaban
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Kathryn Burge
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Steven J McElroy
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, USA
| |
Collapse
|
2
|
El-Farrash RA, Ismail RIH, El-Sheimy MS, Saleh AM, Saleh GA. Enteral administration of a simulated amniotic fluid in preventing feeding intolerance in very low birthweight neonates: A randomized controlled trial. Nutrition 2023; 107:111932. [PMID: 36580871 DOI: 10.1016/j.nut.2022.111932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/23/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Feeding intolerance (FI) is a common finding in preterm neonates. Enteral administration of different forms of amniotic fluid (AF) has been tried for treating FI in high-risk neonates. Simulated amniotic fluid (SAF) is a solution with a similar electrolyte composition to human AF. The aim of this study was to examine whether enteral administration of SAF would improve feeding tolerance in very low birthweight (VLBW) neonates. METHODS Forty VLBW neonates were randomized to either SAF or placebo (total daily dose 20 mL/kg/d-1 divided every 3 h) to their milk for a maximum of 7 d. Neonates with major congenital anomalies, those in whom early feeding was contraindicated, and those treated with parental erythropoietin and/or human granulocyte stimulating factor were excluded. The primary outcome was the total amount of enteral feeds reached by day 7. Secondary outcomes were incidence of FI and necrotizing enterocolitis (NEC). Study intervention was stopped on completing 7 d, reaching enteral feeds of 100 mL/kg/d-1, or the appearance of any sign of FI or NEC. RESULTS All neonates tolerated the test solution well. The SAF group reached significantly larger volume and higher calories on days 3 and 7 (P < 0.05 for all). No statistical differences were seen between the two groups in incidence of FI (P = 0.311), NEC (P = 0.429), mortality (P = 0.632), length of stay (P = 0.744), or weight gain on day 10 (P = 0.389). Baseline hematologic parameters showed no statistical differences before or after enteral administration (P > 0.05). CONCLUSION Results of the present study demonstrated that SAF solution might improve feeding tolerance in VLBW babies without evidence of its systemic absorption. Larger multicenter randomized studies are recommended.
Collapse
Affiliation(s)
- Rania A El-Farrash
- Pediatrics Departments, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Rania I H Ismail
- Pediatrics Departments, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed S El-Sheimy
- Pediatrics Departments, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Ghada A Saleh
- Pediatrics Departments, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| |
Collapse
|
3
|
Early erythropoietin for preventing necrotizing enterocolitis in preterm neonates - an updated meta-analysis. Eur J Pediatr 2022; 181:1821-1833. [PMID: 35122138 DOI: 10.1007/s00431-022-04394-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/20/2021] [Accepted: 01/23/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Previous systematic reviews suggest reduction in necrotizing enterocolitis (NEC) among preterm infants supplemented with erythropoietin (EPO). We aimed to update our 2018 systematic review in this field considering the evidence accumulated over the last 3 years. Randomized controlled trials (RCTs) reporting the effect of early EPO supplementation vs placebo/no EPO supplementation on any stage NEC in preterm infants were included. Fixed effect model was used for meta-analysis. Trial sequential analysis (TSA) was conducted to verify the effects of EPO on NEC after accounting for repeated significance testing. A total of 22 RCTs (n = 5359) were included, of which six were new (n = 2541 additional preterm infants) in comparison to our previous systematic review. EPO significantly decreased the risk of any stage NEC (232/2669 (8.7%) vs 313/2690 (11.6%); RR: 0·76; TSA adjusted 95% CI (0·64, 0·90); p = 0·0008, number needed to treat (NNT) = 34). The risk of definite NEC (≥ Stage II) was also significantly reduced by EPO administration (105/2219 (4.7%) vs 141/2246 (6.3%); RR: 0.77; 95% CI (0.61, 0.98); p = 0.03, NNT: 62). However, the results for definite NEC were no longer significant on sensitivity analyses that included (a) only double-blind RCTs and (b) only prospectively registered trials. The quality of evidence was deemed moderate-to-low for the reported outcomes. CONCLUSION There is moderate to low-quality evidence that early prophylactic EPO reduces any stage and ≥ Stage II NEC in preterm neonates. Prospectively registered, adequately powered, double-blind RCTs are required to confirm these findings. WHAT IS KNOWN • Experimental studies have shown that erythropoietin (EPO) has gastrointestinal trophic effects. • Systematic reviews have shown that early treatment with EPO may decrease the risk of gut injury in preterm or low birth weight infants. WHAT IS NEW • Early EPO supplementation significantly reduced the incidence of any stage NEC and definite NEC in preterm infants < 34 weeks of gestation. • EPO had no significant effect on definite NEC in the analyses that included only double-blinded and prospectively registered RCTs. How might it impact clinical practice in the foreseeable future? • Early prophylactic EPO can be recommended for NEC prevention if its benefits are consistently demonstrated in adequately powered randomized trials with a low risk of bias.
Collapse
|
4
|
de Kroon RR, de Baat T, Senger S, van Weissenbruch MM. Amniotic Fluid: A Perspective on Promising Advances in the Prevention and Treatment of Necrotizing Enterocolitis. Front Pediatr 2022; 10:859805. [PMID: 35359891 PMCID: PMC8964040 DOI: 10.3389/fped.2022.859805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 12/09/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a common and potentially fatal disease that typically affects preterm (PIs) and very low birth weight infants (VLBWIs). Although NEC has been extensively studied, the current therapeutic approaches are unsatisfactory. Due to the similarities in the composition between human amniotic fluid (AF) and human breast milk (BM), which plays a protective role in the development of NEC in PIs and VLBWIs, it has been postulated that AF has similar effects on the outcome of NEC and potential therapeutic implications. AF has been long used for its diagnostic purposes and is often discarded after birth as "biological waste". However, researchers have started to elucidate its therapeutic potential. Experimental studies in animal models have shown that diseases of various organ systems can possibly benefit from AF-based therapy. Hence, we have identified three approaches which show promising results for future clinical application in the prevention and/or treatment of NEC: (1) administration of processed AF (PAF) isolated from donor mothers, (2) administration of AF stem cells (AFSCs), and (3) administration of simulated AF (SAF) formulated to mimic the composition of physiological AF. We have highlighted the most important aspects that should be taken into account to guide further research on the clinical application of AF-based therapy. We hope that this review can provide a framework to identify the challenges of AF-based therapy and help to design future studies to better evaluate AF-based approaches for the treatment and/or prevention of NEC in PIs and VLBWIs.
Collapse
Affiliation(s)
- Rimke Romee de Kroon
- Department of Neonatology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Tessa de Baat
- Department of Neonatology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Stefania Senger
- Department of Mucosal Immunology and Biology Research Center, Massachusetts General Hospital for Children, Boston, MA, United States
| | | |
Collapse
|
5
|
Human Milk Growth Factors and Their Role in NEC Prevention: A Narrative Review. Nutrients 2021; 13:nu13113751. [PMID: 34836007 PMCID: PMC8620589 DOI: 10.3390/nu13113751] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/05/2021] [Accepted: 10/09/2021] [Indexed: 12/25/2022] Open
Abstract
Growing evidence demonstrates human milk's protective effect against necrotizing enterocolitis (NEC). Human milk derives these properties from biologically active compounds that influence intestinal growth, barrier function, microvascular development, and immunological maturation. Among these protective compounds are growth factors that are secreted into milk with relatively high concentrations during the early postnatal period, when newborns are most susceptible to NEC. This paper reviews the current knowledge on human milk growth factors and their mechanisms of action relevant to NEC prevention. It will also discuss the stability of these growth factors with human milk pasteurization and their potential for use as supplements to infant formulas with the goal of preventing NEC.
Collapse
|
6
|
Weeks CL, Marino LV, Johnson MJ. A systematic review of the definitions and prevalence of feeding intolerance in preterm infants. Clin Nutr 2021; 40:5576-5586. [PMID: 34656954 DOI: 10.1016/j.clnu.2021.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Feeding intolerance (FI) is a common phenomenon experienced in preterm infants in neonatal intensive care units, as well as being a focus of many research studies into feeding methods, particularly in relation to comorbidities. There is no widely accepted definition of FI. This systematic review aimed to explore the range of definitions used for FI and provide an estimate of the prevalence amongst preterm infants. METHODS Searches were completed on MEDLINE (includes the Cochrane library), Embase, PsycInfo, CINAHL, NHS Evidence and Web of Science. Inclusion criteria; preterm infants in neonatal units, a clear definition of FI, >10 patients and be available in English language. Case reports were excluded. RESULTS One hundred studies were included. Definitions of FI were inconsistent. Studies were grouped according to definition used into: Group A - measuring gastric residual volume (GRV) only; group B - GRV and abdominal distension (AD); group C - GRV, AD and gastrointestinal symptoms (GI) which included any of vomiting, bilious vomiting and blood in stool; group D- GRV and GI; group E - AD and GI; group F - GI only and group G - any other elements used. Meta-analysis demonstrated that prevalence of FI between groups varied from 15 to 30% with an overall prevalence of 27% (95% confidence interval 23-31%). Group A had the highest prevalence. Review of time to full enteral feed was performed (37 studies) which demonstrated a range of 11.3-18.3 days depending on which FI definition used. DISCUSSION Definitions of FI in research are inconsistent, a similar finding to that seen in studies in both paediatric and adult critical care populations. The difficulty of defining FI in the preterm population is the concern regarding necrotising enterocolitis, with some studies using an overlap in their definitions, despite differing pathophysiology and management. Due to the heterogeneity of data obtained in this review regarding definitions used, further robust research is required in order to conclude which elements which should be used to define FI in this population. PROSPERO NUMBER CRD42019155596. Registered November 2019.
Collapse
Affiliation(s)
- Charlotte L Weeks
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK.
| | - Luise V Marino
- Department of Dietetics/SLT, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Mark J Johnson
- NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK; Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| |
Collapse
|
7
|
de Lange IH, van Gorp C, Eeftinck Schattenkerk LD, van Gemert WG, Derikx JPM, Wolfs TGAM. Enteral Feeding Interventions in the Prevention of Necrotizing Enterocolitis: A Systematic Review of Experimental and Clinical Studies. Nutrients 2021; 13:1726. [PMID: 34069699 PMCID: PMC8161173 DOI: 10.3390/nu13051726] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/14/2021] [Accepted: 05/15/2021] [Indexed: 12/11/2022] Open
Abstract
Necrotizing enterocolitis (NEC), which is characterized by severe intestinal inflammation and in advanced stages necrosis, is a gastrointestinal emergency in the neonate with high mortality and morbidity. Despite advancing medical care, effective prevention strategies remain sparse. Factors contributing to the complex pathogenesis of NEC include immaturity of the intestinal immune defense, barrier function, motility and local circulatory regulation and abnormal microbial colonization. Interestingly, enteral feeding is regarded as an important modifiable factor influencing NEC pathogenesis. Moreover, breast milk, which forms the currently most effective prevention strategy, contains many bioactive components that are known to support neonatal immune development and promote healthy gut colonization. This systematic review describes the effect of different enteral feeding interventions on the prevention of NEC incidence and severity and the effect on pathophysiological mechanisms of NEC, in both experimental NEC models and clinical NEC. Besides, pathophysiological mechanisms involved in human NEC development are briefly described to give context for the findings of altered pathophysiological mechanisms of NEC by enteral feeding interventions.
Collapse
Affiliation(s)
- Ilse H. de Lange
- European Surgical Center Aachen/Maastricht, Department of Pediatric Surgery, School for Nutrition, Toxicology and Metabolism (NUTRIM), 6202 AZ Maastricht, The Netherlands; (I.H.d.L.); (W.G.v.G.)
- Department of Surgery, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, 6202 AZ Maastricht, The Netherlands
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands;
| | - Charlotte van Gorp
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands;
| | - Laurens D. Eeftinck Schattenkerk
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands; (L.D.E.S.); (J.P.M.D.)
| | - Wim G. van Gemert
- European Surgical Center Aachen/Maastricht, Department of Pediatric Surgery, School for Nutrition, Toxicology and Metabolism (NUTRIM), 6202 AZ Maastricht, The Netherlands; (I.H.d.L.); (W.G.v.G.)
- Department of Surgery, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, 6202 AZ Maastricht, The Netherlands
| | - Joep P. M. Derikx
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands; (L.D.E.S.); (J.P.M.D.)
| | - Tim G. A. M. Wolfs
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands;
- Department of Biomedical Engineering (BMT), School for Cardiovascular Diseases (CARIM), Maastricht University, 6202 AZ Maastricht, The Netherlands
| |
Collapse
|
8
|
Vaes JEG, Brandt MJV, Wanders N, Benders MJNL, de Theije CGM, Gressens P, Nijboer CH. The impact of trophic and immunomodulatory factors on oligodendrocyte maturation: Potential treatments for encephalopathy of prematurity. Glia 2020; 69:1311-1340. [PMID: 33595855 PMCID: PMC8246971 DOI: 10.1002/glia.23939] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
Encephalopathy of prematurity (EoP) is a major cause of morbidity in preterm neonates, causing neurodevelopmental adversities that can lead to lifelong impairments. Preterm birth-related insults, such as cerebral oxygen fluctuations and perinatal inflammation, are believed to negatively impact brain development, leading to a range of brain abnormalities. Diffuse white matter injury is a major hallmark of EoP and characterized by widespread hypomyelination, the result of disturbances in oligodendrocyte lineage development. At present, there are no treatment options available, despite the enormous burden of EoP on patients, their families, and society. Over the years, research in the field of neonatal brain injury and other white matter pathologies has led to the identification of several promising trophic factors and cytokines that contribute to the survival and maturation of oligodendrocytes, and/or dampening neuroinflammation. In this review, we discuss the current literature on selected factors and their therapeutic potential to combat EoP, covering a wide range of in vitro, preclinical and clinical studies. Furthermore, we offer a future perspective on the translatability of these factors into clinical practice.
Collapse
Affiliation(s)
- Josine E G Vaes
- Department for Developmental Origins of Disease, University Medical Center Utrecht Brain Center and Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands.,Department of Neonatology, University Medical Center Utrecht Brain Center and Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Myrna J V Brandt
- Department for Developmental Origins of Disease, University Medical Center Utrecht Brain Center and Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Nikki Wanders
- Department for Developmental Origins of Disease, University Medical Center Utrecht Brain Center and Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, University Medical Center Utrecht Brain Center and Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Caroline G M de Theije
- Department for Developmental Origins of Disease, University Medical Center Utrecht Brain Center and Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | | | - Cora H Nijboer
- Department for Developmental Origins of Disease, University Medical Center Utrecht Brain Center and Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
9
|
Enteral Bioactive Factor Supplementation in Preterm Infants: A Systematic Review. Nutrients 2020; 12:nu12102916. [PMID: 32987621 PMCID: PMC7598610 DOI: 10.3390/nu12102916] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/24/2022] Open
Abstract
Feeding preterm infants with mother’s own milk is associated with a reduction in postnatal complications and an improved neurocognitive outcome. Therefore, the bioactive factor composition of human milk has been used as a tool for the development of nutritional supplements with a potential prophylactic or therapeutic effect. The aim of this systematic review was to provide an overview on bioactive factors which have been studied as supplement to enteral nutrition in randomized controlled trials, and to provide an overview of ongoing trials. MEDLINE, EMBASE, CENTRAL, and clinical trial registers were searched. Studies on the antimicrobial protein lactoferrin were excluded as these were summarized very recently in three separate systematic reviews. Studies on vitamins D, K and iron were also excluded as they are already incorporated in most international guidelines. We identified 17 different bioactive factors, which were investigated in 26 studies. Despite the encouraging potential effects of several bioactive factors, more high-quality studies with a sufficient number of preterm infants are required before a certain factor may be implemented into clinical practice. Three large trials (n > 500) that investigate the effects of either enteral insulin or vitamin A are currently ongoing and could provide more definite answers on these specific supplements.
Collapse
|
10
|
Baumgarten HD, Hartman HA, Butt Z, Ozawa K, Rossidis AC, Lawrence KM, Kim AG, Davey M, Flake AW. A Rabbit Model for Optimization of Amniotic Fluid Components in the EXTrauterine Environment for Newborn Development (EXTEND) System. Fetal Diagn Ther 2020; 47:939-946. [PMID: 32877895 DOI: 10.1159/000509247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
In this model article, we present a protocol for continuous amniotic fluid exchange in rabbits using a novel system to test the effects of growth factor-deficient, artificial amniotic fluid on bowel development. BACKGROUND Ideally, the EXTrauterine Environment for Neonatal Development (EXTEND) will provide physiologic support to the extreme premature infant. An important component of that environment is the amniotic fluid. Thus, we developed an animal model to study the growth factors found within amniotic fluid and inform design of a synthetic fluid to optimize fetal development. METHODS We designed a model of amniotic fluid exchange within the pregnant rabbit, continuously removing the natural fluid from around 2 fetuses per doe and replacing it with a physiologic electrolyte solution during the final 100 h of gestation. Two fetuses from the contralateral uterine horn were used as sham-operated controls. Thirty-eight fetuses were analyzed, 19 in each group. We analyzed the fetal growth and bowel development. RESULTS Ultrasound after 100 h of exchange showed equivalent fluid volumes, p = 0.63. Cultures were negative for bacterial colonization. Final fluid protein concentrations were 11.6% that of control fluid (mean 1,451 ± 224.2 vs. 12,491 ± 849.2 μg/mL). There was no significant difference in fetal growth, with experimental weights 91.4% of control weights, p = 0.07. Fetal bowel weights (90.1%, p = 0.16) and lengths (94.2%, p = 0.49) were also not significantly less compared to controls. There was no significant difference in villous height or crypt depth measurements between the groups, and absorptive capacity of the bowel was not different between groups, p = 0.44. CONCLUSION This animal model allows for manipulation of the components of amniotic fluid. Marked reduction of natural amniotic fluid proteins during gestation does not appear to significantly impair fetal growth or bowel development. Further work with this model will assess the importance of amniotic fluid components for normal development to inform design of a synthetic fluid for use during EXTEND.
Collapse
Affiliation(s)
- Heron D Baumgarten
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Heather A Hartman
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Zoya Butt
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Katsusuke Ozawa
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Avery C Rossidis
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Kendall M Lawrence
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Aimee G Kim
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Marcus Davey
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA
| | - Alan W Flake
- The Children's Hospital of Philadelphia Research Institute and the Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Center, Philadelphia, Pennsylvania, USA,
| |
Collapse
|
11
|
Wang Y, Song J, Sun H, Xu F, Li K, Nie C, Zhang X, Peng X, Xia L, Shen Z, Yuan X, Zhang S, Ding X, Zhang Y, Kang W, Qian L, Zhou W, Wang X, Cheng X, Zhu C. Erythropoietin prevents necrotizing enterocolitis in very preterm infants: a randomized controlled trial. J Transl Med 2020; 18:308. [PMID: 32771013 PMCID: PMC7414749 DOI: 10.1186/s12967-020-02459-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/26/2020] [Indexed: 02/07/2023] Open
Abstract
Background Necrotizing enterocolitis (NEC) is one of the most severe complications in very preterm infants, but there are currently no accepted methods to prevent NEC. Studies have shown that erythropoietin (EPO) has the potential to prevent NEC or improve outcomes of preterm NEC. This study aimed to determine whether recombinant human EPO (rhEPO) could protect against NEC in very preterm infants. Methods The study was a prospective randomized clinical trial performed among four NICU centers. A total of 1327 preterm infants with gestational age ≤ 32 weeks were admitted to the centers, and 42 infants were excluded leaving 1285 eligible infants to be randomized to the rhEPO or control group. Infants in the rhEPO group were given 500 IU/kg rhEPO intravenously every other day for 2 weeks, while the control group was given the same volume of saline. The primary outcome was the incidence of NEC in very preterm infants at 36 weeks of corrected gestational age. Results A total of 1285 infants were analyzed at 36 weeks of corrected age for the incidence of NEC. rhEPO treatment significantly decreased the incidence of NEC (stage I, II and III) (12.0% vs. 17.1%, p = 0.010), especially confirmed NEC (stage II and III) (3.0% vs. 5.4%, p = 0.027). Meanwhile, rhEPO treatment significantly reduced the number of red blood cells transfusion in the confirmed NEC cases (1.2 ± 0.4 vs. 2.7 ± 1.0, p = 0.004). Subgroup analyses showed that rhEPO treatment significantly decreased the incidence of confirmed NEC at gestational age < 28 weeks (p = 0.019), and the incidence of all stages NEC in preterm infants with hemoglobin < 90 g/l (p = 0.000) and 5 min Apgar score > 5 (p = 0.028). Conclusion Repeated low-dose rhEPO treatment is beneficial against NEC in very preterm infants. Trial registration The protocol was registered retrospectively at ClinicalTrials.gov (NCT03919500) on April 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03919500
Collapse
Affiliation(s)
- Yong Wang
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Juan Song
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Huiqing Sun
- Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, 450018, China
| | - Falin Xu
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Kenan Li
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Chunxia Nie
- Department of Neonatology, Women and Children Health Care Center of Luoyang, Luoyang, 471000, China
| | - Xiaoli Zhang
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Xirui Peng
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Lei Xia
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Ziyun Shen
- Department of Neonatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Xiao Yuan
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Shan Zhang
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Xue Ding
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yaodong Zhang
- Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, 450018, China
| | - Wenqing Kang
- Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, 450018, China
| | - Liling Qian
- Department of Pediatrics, Children's Hospital of Fudan University, Shanghai, China
| | - Wenhao Zhou
- Department of Pediatrics, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaoyang Wang
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.,Center of Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 40530, Gothenburg, Sweden
| | - Xiuyong Cheng
- Department of Neonatology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Department of Neonatology, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China. .,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 40530, Gothenburg, Sweden. .,Department of Women's and Children's Health, Karolinska Institutet, 17176, Stockholm, Sweden.
| |
Collapse
|
12
|
Baumgarten HD, Wright CM, Rossidis AC, Lawrence KM, Kim AG, Mejaddam AY, McGovern PE, Orr MN, Coons BE, Butt Z, Li H, Hwang G, Radu A, Brown LJ, Rubenstein RC, Peranteau WH, Davey M, Heuckeroth RO, Flake AW. The EXTrauterine Environment for Neonatal Development Supports Normal Intestinal Maturation and Development. Cell Mol Gastroenterol Hepatol 2020; 10:623-637. [PMID: 32474164 PMCID: PMC7408362 DOI: 10.1016/j.jcmgh.2020.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS The Extra-Uterine Environment for Neonatal Development (EXTEND) aims to avoid the complications of prematurity, such as NEC. Our goal was to determine if bowel development occurs normally in EXTEND-supported lambs, with specific emphasis on markers of immaturity associated with NEC. METHODS We compared terminal ileum from 17 pre-term lambs supported on EXTEND for 2- 4 weeks to bowel from age-matched fetal lambs that developed in utero. We evaluated morphology, markers of epithelial integrity and maturation, enteric nervous system structure, and bowel motility. RESULTS EXTEND-supported lamb ileum had normal villus height, crypt depth, density of mucin-containing goblet cells, and enteric neuron density. Expression patterns for I-FABP, activated caspase-3 and EGFR were normal in bowel epithelium. Transmural resistance assessed in Ussing chambers was normal. Bowel motility was also normal as assessed by ex vivo organ bath and video imaging. However, Peyer's patch organization did not occur normally in EXTEND ileum, resulting in fewer circulating B cells in experimental animals. CONCLUSION EXTEND supports normal ileal epithelial and enteric nervous system maturation in pre-term lambs. The classic morphologic changes and cellular expression profiles associated with NEC are not seen. However, immune development within the EXTEND supported lamb bowel does not progress normally.
Collapse
Affiliation(s)
- Heron D Baumgarten
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina M Wright
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Avery C Rossidis
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kendall M Lawrence
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aimee G Kim
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali Y Mejaddam
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick E McGovern
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa N Orr
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Barbara E Coons
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zoya Butt
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haiying Li
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace Hwang
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Antoneta Radu
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren J Brown
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronald C Rubenstein
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William H Peranteau
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcus Davey
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert O Heuckeroth
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan W Flake
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
13
|
Omar OM, Massoud MN, Ghazal H, Hassouna H, Somaa MF. Effect of enteral erythropoietin on feeding-related complications in preterm newborns: A pilot randomized controlled study. Arab J Gastroenterol 2020; 21:37-42. [PMID: 32241699 DOI: 10.1016/j.ajg.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/11/2019] [Accepted: 01/26/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND STUDY AIMS To evaluate the effects of enteral administration of recombinant human erythropoietin (rhEPO) on feeding-related complications in preterm infants. PATIENTS AND METHODS This double-blind, randomized controlled pilot study enrolled 120 preterm infants born ≤ 32 weeks' gestation who were admitted to the neonatal intensive care unit in a tertiary hospital; 60 patients randomly received recombinant human erythropoietin while the other 60 received placebo. Newborns who underwent cardiopulmonary resuscitation, infants with genetic syndromes, infants with inborn errors of metabolism, infants with major congenital or acquired gastrointestinal tract malformations, infants with previous use of parenteral growth factors such as recombinant human erythropoietin and granulocyte-macrophage colony-stimuating factor (GM-CSF) and infants previously treated with intravenous immunoglobulin were excluded. Overall, 48 patients withdrew from the study because of intravenous haematopoietic growth factor intake or death before treatment was completed. A total of 72 preterm infants remained in the study: 36 preterm infants in the erythropoietin (EPO) group, and 36 preterm infants in the placebo group. The day that enteral feeding was successfully started, the time to establishing one-half, two-thirds, and full enteral feedings (reaching at least 150 mL/kg/day), the number of episodes of feeding intolerance, the time to regain birth weight and the incidence of necrotizing enterocolitis (NEC) were recorded. RESULTS Both groups showed no significant difference in the time to achieve one-half, two-thirds, or full enteral feeding, no signs of feeding intolerance, and no cases of NEC were recorded. CONCLUSION Enteral erythropoietin does not appear to affect feeding intolerance or NEC incidence.
Collapse
Affiliation(s)
- Omneya M Omar
- Department of Paediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Mohamed N Massoud
- Department of Paediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hesham Ghazal
- Department of Paediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hadir Hassouna
- Department of Paediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mai F Somaa
- Department of Paediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| |
Collapse
|
14
|
Abstract
BACKGROUND Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia and to provide neuro protection and protection against necrotising enterocolitis (NEC). Darbepoetin (Darbe) and EPO are currently available ESAs. OBJECTIVES To assess the effectiveness and safety of ESAs (erythropoietin (EPO) and/or Darbe) initiated early (before eight days after birth) compared with placebo or no intervention in reducing red blood cell (RBC) transfusions, adverse neurological outcomes, and feeding intolerance including necrotising enterocolitis (NEC) in preterm and/or low birth weight infants. Primary objective for studies that primarily investigate the effectiveness and safety of ESAs administered early in reducing red blood cell transfusions: To assess the effectiveness and safety of ESAs initiated early in reducing red blood cell transfusions in preterm infants. Secondary objectives: Review authors performed subgroup analyses of low (≤ 500 IU/kg/week) and high (> 500 IU/kg/week) doses of EPO and the amount of iron supplementation provided: none, low (≤ 5 mg/kg/d), and high (> 5 mg/kg/d). Primary objective for studies that primarily investigate the neuro protective effectiveness of ESAs: To assess the effectiveness and safety of ESAs initiated early in reducing adverse neurological outcomes in preterm infants. Primary objective for studies that primarily investigate the effectiveness of EPO or Darbe administered early in reducing feeding intolerance: To assess the effectiveness and safety of ESAs administered early in reducing feeding intolerance (and NEC) in preterm infants. Other secondary objectives: To compare the effectiveness of ESAs in reducing the incidence of adverse events and improving long-term neurodevelopmental outcomes. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE via PubMed (1966 to 10 March 2017), Embase (1980 to 10 March 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 10 March 2017). We searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised and quasi-randomised controlled trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of early initiation of EAS treatment versus placebo or no intervention in preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS We used the methods described in the Cochrane Handbook for Systematic Reviews of Interventions and the GRADE approach to assess the quality of evidence. MAIN RESULTS This updated review includes 34 studies enrolling 3643 infants. All analyses compared ESAs versus a control consisting of placebo or no treatment. Early ESAs reduced the risk of 'use of one or more [red blood cell] RBC transfusions' (typical risk ratio (RR) 0.79, 95% confidence interval (CI) 0.74 to 0.85; typical risk difference (RD) -0.14, 95% CI -0.18 to -0.10; I2 = 69% for RR and 62% for RD (moderate heterogeneity); number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 6 to 10; 19 studies, 1750 infants). The quality of the evidence was low. Necrotising enterocolitis was significantly reduced in the ESA group compared with the placebo group (typical RR 0.69, 95% CI 0.52 to 0.91; typical RD -0.03, 95% CI -0.05 to -0.01; I2 = 0% for RR and 22% for RD (low heterogeneity); NNTB 33, 95% CI 20 to 100; 15 studies, 2639 infants). The quality of the evidence was moderate. Data show a reduction in 'Any neurodevelopmental impairment at 18 to 22 months' corrected age in the ESA group (typical RR 0.62, 95% CI 0.48 to 0.80; typical RD -0.08, 95% CI -0.12 to -0.04; NNTB 13, 95% CI 8 to 25. I2 = 76% for RR (high heterogeneity) and 66% for RD (moderate); 4 studies, 1130 infants). The quality of the evidence was low. Results reveal increased scores on the Bayley-II Mental Development Index (MDI) at 18 to 24 months in the ESA group (weighted mean difference (WMD) 8.22, 95% CI 6.52 to 9.92; I2 = 97% (high heterogeneity); 3 studies, 981 children). The quality of the evidence was low. The total volume of RBCs transfused per infant was reduced by 7 mL/kg. The number of RBC transfusions per infant was minimally reduced, but the number of donors to whom infants who were transfused were exposed was not significantly reduced. Data show no significant difference in risk of stage ≥ 3 retinopathy of prematurity (ROP) with early EPO (typical RR 1.24, 95% CI 0.81 to 1.90; typical RD 0.01, 95% CI -0.02 to 0.04; I2 = 0% (no heterogeneity) for RR; I2 = 34% (low heterogeneity) for RD; 8 studies, 1283 infants). Mortality was not affected, but results show significant reductions in the incidence of intraventricular haemorrhage (IVH) and periventricular leukomalacia (PVL). AUTHORS' CONCLUSIONS Early administration of ESAs reduces the use of red blood cell (RBC) transfusions, the volume of RBCs transfused, and donor exposure after study entry. Small reductions are likely to be of limited clinical importance. Donor exposure probably is not avoided, given that all but one study included infants who had received RBC transfusions before trial entry. This update found no significant difference in the rate of ROP (stage ≥ 3) for studies that initiated EPO treatment at less than eight days of age, which has been a topic of concern in earlier versions of this review. Early EPO treatment significantly decreased rates of IVH, PVL, and NEC. Neurodevelopmental outcomes at 18 to 22 months and later varied in published studies. Ongoing research should evaluate current clinical practices that will limit donor exposure. Promising but conflicting results related to the neuro protective effect of early EPO require further study. Very different results from the two largest published trials and high heterogeneity in the analyses indicate that we should wait for the results of two ongoing large trials before drawing firm conclusions. Administration of EPO is not currently recommended because limited benefits have been identified to date. Use of darbepoetin requires further study.
Collapse
Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
| | - Sanjay M Aher
- Neocare HospitalNeonatal Intensive Care UnitMumbai NakaNashikMaharashtraIndia422002
| | | |
Collapse
|
15
|
Krieg D, Svilenov H, Gitter JH, Winter G. Overcoming challenges in co-formulation of proteins with contradicting stability profiles - EPO plus G-CSF. Eur J Pharm Sci 2020; 141:105073. [DOI: 10.1016/j.ejps.2019.105073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/25/2019] [Accepted: 09/12/2019] [Indexed: 02/06/2023]
|
16
|
Teramo K, Piñeiro-Ramos JD. Fetal chronic hypoxia and oxidative stress in diabetic pregnancy. Could fetal erythropoietin improve offspring outcomes? Free Radic Biol Med 2019; 142:32-37. [PMID: 30898666 DOI: 10.1016/j.freeradbiomed.2019.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/26/2019] [Accepted: 03/11/2019] [Indexed: 12/18/2022]
Abstract
Oxidative stress is responsible for microvascular complications (hypertension, nephropathy, retinopathy, peripheral neuropathy) of diabetes, which during pregnancy increase both maternal and fetal complications. Chronic hypoxia and hyperglycemia result in increased oxidative stress and decreased antioxidant enzyme activity. However, oxidative stress induces also anti-oxidative reactions both in pregnant diabetes patients and in their fetuses. Not all type 1 diabetes patients with long-lasting disease develop microvascular complications, which suggests that some of these patients have protective mechanisms against these complications. Fetal erythropoietin (EPO) is the main regulator of red cell production in the mother and in the fetus, but it has also protective effects in various maternal and fetal tissues. This dual effect of EPO is based on EPO receptor (EPO-R) isoforms, which differ structurally and functionally from the hematopoietic EPO-R isoform. The tissue protective effects of EPO are based on its anti-apoptotic, anti-oxidative, anti-inflammatory, cell proliferative and angiogenic properties. Recent experimental and clinical studies have shown that EPO has also positive metabolic effects on hyperglycemia and diabetes, although these have not yet been fully delineated. Whether the tissue protective and metabolic effects of EPO could have clinical benefits, are important topics for future research in diabetic pregnancies.
Collapse
Affiliation(s)
- Kari Teramo
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | | |
Collapse
|
17
|
El-Farrash RA, Gad GI, Abdelkader HM, Salem DADD, Fahmy SA. Simulated amniotic fluid-like solution given enterally to neonates after obstructive bowel surgeries: A randomized controlled trial. Nutrition 2019; 66:187-191. [PMID: 31310960 DOI: 10.1016/j.nut.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Withholding postoperative feeding is common in neonates recovering from surgeries for congenital abnormalities of the gastrointestinal tract (GIT), which leads to prolonged exposure to total parenteral nutrition, intestinal atrophy, and feeding intolerance. Because amniotic fluid plays a significant role in fetal gut maturation and development, the aim of this study was to test a hypothesis suggesting that feeding tolerance could be improved in neonates recovering from surgeries for congenital obstructive bowel abnormalities by enteral administration of simulated amniotic fluid-like solution given enterally (SAFE) containing recombinant human granulocyte colony-stimulating factor and erythropoietin. METHODS This prospective, double-blind, randomized, placebo-controlled trial was conducted with 40 late preterm/term neonates recovering from GIT surgeries. Neonates were randomly divided postoperatively into two groups: 20 neonates received the test solution (SAFE group) and 20 neonates received distilled water (placebo group) with a gestational age range (34.3-40.4 versus 34-40 wk, respectively) and mean gestational age (37.10 ± 1.68 versus 36.90 ± 1.83 wk, respectively). Treatment was started postoperatively and the test solution (or distilled water) was discontinued when daily enteral intake reached 100 mL/kg. RESULTS The study group showed better feeding tolerance as demonstrated as reflected by an earlier achievement of 50, 100, 120, and 150 mL/kg enteral feeding per day with a higher enteral caloric intake on day 7 post SAFE administration and a higher rate of weight gain (P < 0.05 for all). CONCLUSION Enteral administration of SAFE may improve postoperative feeding tolerance, enteral caloric intake, and weight gain.
Collapse
Affiliation(s)
- Rania Ali El-Farrash
- Department of Pediatrics-Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Ghada Ibrahim Gad
- Department of Pediatrics-Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | | |
Collapse
|
18
|
Shelby RD, Cromeens B, Rager TM, Besner GE. Influence of Growth Factors on the Development of Necrotizing Enterocolitis. Clin Perinatol 2019; 46:51-64. [PMID: 30771819 PMCID: PMC6380490 DOI: 10.1016/j.clp.2018.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Growth factors have important roles in gastrointestinal tract development, maintenance, and response to injury. Various experiments have been used to demonstrate growth factor influence in multiple disease processes. These studies demonstrated enhancement of mucosal proliferation, intestinal motility, immune modulation, and many other beneficial effects. Select growth factors, including epidermal growth factor and heparin-binding epidermal growth factor like growth factor, demonstrate some beneficial effects in experimental and clinical intestinal injury demonstrated in necrotizing enterocolitis. The roles of glucagon-like peptide 2, insulin-like growth factor 1, erythropoietin, growth hormone, and hepatocyte growth factor in necrotizing enterocolitis are summarized in this article.
Collapse
Affiliation(s)
- Rita D. Shelby
- Surgical Research Fellow, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Barrett Cromeens
- Surgical Research Fellow, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Terrance M Rager
- Surgical Research Fellow, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Gail E. Besner
- Chief, Department of Pediatric Surgery, H. William Clatworthy, Jr. Professor of Surgery, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| |
Collapse
|
19
|
Robust increases in erythropoietin production by the hypoxic fetus is a response to protect the brain and other vital organs. Pediatr Res 2018; 84:807-812. [PMID: 29895839 PMCID: PMC6291371 DOI: 10.1038/s41390-018-0054-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/16/2018] [Accepted: 03/22/2018] [Indexed: 01/22/2023]
Abstract
Fetal erythropoietin (EPO), in addition to regulating erythropoiesis, has also tissue-protective properties based on its anti-inflammatory, anti-apoptotic, antioxidant, and neurotrophic effects. Notably, EPO concentrations needed for tissue protection are 100-1000 times higher than concentrations needed for regulating erythropoiesis. This dual effect of EPO is based on EPO-receptor (EPO-R) isoforms, which differ structurally and functionally. We hypothesize in this Integrated Mechanism Review that during severe fetal hypoxia the observed, but poorly understood, marked increases of fetal plasma EPO concentrations occur to protect the brain, heart, and other vital fetal organs. We further hypothesize that the concurrent marked increases of EPO in the amniotic fluid during fetal hypoxia, occur to protect newborn infants from necrotizing enterocolitis. This review presents experimental and clinical evidence in support of these hypotheses and points out unknown or poorly understood functions of EPO in the fetus. If these novel hypotheses are correct, the importance of fetal EPO as an antenatal hypoxia biomarker will become apparent. It will also likely point the way to important diagnostic and therapeutic fetal and neonatal interventions.
Collapse
|
20
|
Ananthan A, Balasubramanian H, Rao S, Patole S. Clinical Outcomes Related to the Gastrointestinal Trophic Effects of Erythropoietin in Preterm Neonates: A Systematic Review and Meta-Analysis. Adv Nutr 2018; 9:238-246. [PMID: 29767696 PMCID: PMC5952937 DOI: 10.1093/advances/nmy005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 01/11/2018] [Indexed: 01/01/2023] Open
Abstract
Erythropoietin (EPO) plays an important role in the development and maturation of the gastrointestinal tract. Recombinant EPO (rEPO) has been used to prevent anemia of prematurity. The gastrointestinal trophic effects of EPO may reduce feeding intolerance and necrotizing enterocolitis (NEC) in preterm neonates. The aim of this systematic review of randomized controlled trials (RCTs) was to evaluate the effects of rEPO on clinical outcomes such as feeding intolerance, stage II or higher NEC, any stage NEC, sepsis, retinopathy of prematurity, and bronchopulmonary dysplasia in preterm neonates. Twenty-five RCTs (intravenous: 13; subcutaneous: 10; enteral: 2; n = 4025) were eligible for inclusion. Meta-analysis of data from 17 RCTs (rEPO compared with placebo) with the use of a fixed-effects model showed no significant effect of rEPO on stage II or higher NEC (RR: 0.87; 95% CI: 0.64, 1.19; P = 0.39). Meta-analysis of data from 25 RCTs (rEPO compared with placebo) showed that rEPO significantly decreased the risk of any stage NEC [cases/total sample: 120/2058 (5.83%) compared with 146/1967 (7.42%); RR: 0.77; 95% CI: 0.61, 0.97; P = 0.03]. Only one RCT reported on time to full feedings. Meta-analysis of data from 15 RCTs showed a significant reduction in late-onset sepsis after rEPO administration (RR: 0.81; 95% CI: 0.71, 0.94; P = 0.004). Meta-analysis of 13 RCTs showed no significant effect of rEPO on mortality, retinopathy of prematurity, and bronchopulmonary dysplasia. Prophylactic rEPO had no effect on stage II or higher NEC, but it reduced any stage NEC, probably by reducing feeding intolerance, which is often labeled as stage I NEC. Adequately powered RCTs are required to confirm these findings.
Collapse
Affiliation(s)
- Anitha Ananthan
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India,Address correspondence to AA (e-mail: )
| | | | - Shripada Rao
- Department of Neonatal Pediatrics, Princess Margaret Hospital for Children, Perth, Western Australia, Australia,Center for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Sanjay Patole
- Center for Neonatal Research and Education, University of Western Australia, Perth, Australia,Department of Neonatal Pediatrics, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| |
Collapse
|
21
|
Abstract
BACKGROUND Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia and to provide neuro protection and protection against necrotising enterocolitis (NEC). Darbepoetin (Darbe) and EPO are currently available ESAs. OBJECTIVES To assess the effectiveness and safety of ESAs (erythropoietin (EPO) and/or Darbe) initiated early (before eight days after birth) compared with placebo or no intervention in reducing red blood cell (RBC) transfusions, adverse neurological outcomes, and feeding intolerance including necrotising enterocolitis (NEC) in preterm and/or low birth weight infants. Primary objective for studies that primarily investigate the effectiveness and safety of ESAs administered early in reducing red blood cell transfusions:To assess the effectiveness and safety of ESAs initiated early in reducing red blood cell transfusions in preterm infants. Secondary objectives:Review authors performed subgroup analyses of low (≤ 500 IU/kg/week) and high (> 500 IU/kg/week) doses of EPO and the amount of iron supplementation provided: none, low (≤ 5 mg/kg/d), and high (> 5 mg/kg/d). Primary objective for studies that primarily investigate the neuro protective effectiveness of ESAs:To assess the effectiveness and safety of ESAs initiated early in reducing adverse neurological outcomes in preterm infants. Primary objective for studies that primarily investigate the effectiveness of EPO or Darbe administered early in reducing feeding intolerance:To assess the effectiveness and safety of ESAs administered early in reducing feeding intolerance (and NEC) in preterm infants. Other secondary objectives:To compare the effectiveness of ESAs in reducing the incidence of adverse events and improving long-term neurodevelopmental outcomes. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE via PubMed (1966 to 10 March 2017), Embase (1980 to 10 March 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 10 March 2017). We searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised and quasi-randomised controlled trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of early initiation of EAS treatment versus placebo or no intervention in preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS We used the methods described in the Cochrane Handbook for Systematic Reviews of Interventions and the GRADE approach to assess the quality of evidence. MAIN RESULTS This updated review includes 34 studies enrolling 3643 infants. All analyses compared ESAs versus a control consisting of placebo or no treatment.Early ESAs reduced the risk of 'use of one or more [red blood cell] RBC transfusions' (typical risk ratio (RR) 0.79, 95% confidence interval (CI) 0.74 to 0.85; typical risk difference (RD) -0.14, 95% CI -0.18 to -0.10; I2 = 69% for RR and 62% for RD (moderate heterogeneity); number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 6 to 10; 19 studies, 1750 infants). The quality of the evidence was low.Necrotising enterocolitis was significantly reduced in the ESA group compared with the placebo group (typical RR 0.69, 95% CI 0.52 to 0.91; typical RD -0.03, 95% CI -0.05 to -0.01; I2 = 0% for RR and 22% for RD (low heterogeneity); NNTB 33, 95% CI 20 to 100; 15 studies, 2639 infants). The quality of the evidence was moderate.Data show a reduction in 'Any neurodevelopmental impairment at 18 to 22 months' corrected age in the ESA group (typical RR 0.62, 95% CI 0.48 to 0.80; typical RD -0.08, 95% CI -0.12 to -0.04; NNTB 13, 95% CI 8 to 25. I2 = 76% for RR (high heterogeneity) and 66% for RD (moderate); 4 studies, 1130 infants). The quality of the evidence was low.Results reveal increased scores on the Bayley-II Mental Development Index (MDI) at 18 to 24 months in the ESA group (weighted mean difference (WMD) 8.22, 95% CI 6.52 to 9.92; I2 = 97% (high heterogeneity); 3 studies, 981 children). The quality of the evidence was low.The total volume of RBCs transfused per infant was reduced by 7 mL/kg. The number of RBC transfusions per infant was minimally reduced, but the number of donors to whom infants who were transfused were exposed was not significantly reduced. Data show no significant difference in risk of stage ≥ 3 retinopathy of prematurity (ROP) with early EPO (typical RR 1.24, 95% CI 0.81 to 1.90; typical RD 0.01, 95% CI -0.02 to 0.04; I2 = 0% (no heterogeneity) for RR; I2 = 34% (low heterogeneity) for RD; 8 studies, 1283 infants). Mortality was not affected, but results show significant reductions in the incidence of intraventricular haemorrhage (IVH) and periventricular leukomalacia (PVL). AUTHORS' CONCLUSIONS Early administration of ESAs reduces the use of red blood cell (RBC) transfusions, the volume of RBCs transfused, and donor exposure after study entry. Small reductions are likely to be of limited clinical importance. Donor exposure probably is not avoided, given that all but one study included infants who had received RBC transfusions before trial entry. This update found no significant difference in the rate of ROP (stage ≥ 3) for studies that initiated EPO treatment at less than eight days of age, which has been a topic of concern in earlier versions of this review. Early EPO treatment significantly decreased rates of IVH, PVL, and NEC. Neurodevelopmental outcomes at 18 to 22 months and later varied in published studies. Ongoing research should evaluate current clinical practices that will limit donor exposure. Promising but conflicting results related to the neuro protective effect of early EPO require further study. Very different results from the two largest published trials and high heterogeneity in the analyses indicate that we should wait for the results of two ongoing large trials before drawing firm conclusions. Administration of EPO is not currently recommended because limited benefits have been identified to date. Use of darepoetin requires further study.
Collapse
Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1X5
| | - Sanjay M Aher
- Neocare HospitalNeonatal Intensive Care UnitMumbai NakaNashikIndia422002
| |
Collapse
|
22
|
Abstract
The immune system of preterm infants is immature, placing them at increased risk for serious immune-related complications. Human milk provides a variety of immune protective and immune maturation factors that are beneficial to the preterm infant's poorly developed immune system. The most studied immune components in human milk include antimicrobial proteins, maternal leukocytes, immunoglobulins, cytokines and chemokines, oligosaccharides, gangliosides, nucleotides, and long-chain polyunsaturated fatty acids. There is growing evidence that these components contribute to the lower incidence of immune-related conditions in the preterm infant. Therefore, provision of these components in human milk, donor milk, or formula may provide immunologic benefits.
Collapse
|
23
|
Abstract
Necrotizing enterocolitis is a devastating intestinal disease that affects ~5% of preterm neonates. Despite advancements in neonatal care, mortality remains high (30–50%) and controversy still persists with regards to the most appropriate management of neonates with necrotizing enterocolitis. Herein, we review some controversial aspects regarding the epidemiology, imaging, medical and surgical management of necrotizing enterocolitis and we describe new emerging strategies for prevention and treatment.
Collapse
Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| |
Collapse
|